Disease management is an approach to patient care and medical cost control that is based on the premise that a minority of healthcare users generate the majority of total healthcare costs. Disease management programs use information technology to identify individuals who have or are at risk for various adverse medical conditions. Disease management programs offer customized education and clinical support to help individuals take more responsibility for self-care, improve their health, and avoid expensive medical events down the road. By proactively improving the health of the minority of a population that consumes the majority of healthcare resources, disease management programs can significantly reduce many preventable medical expenses, including hospitalization and ER visits.
Disease management programs commonly segment an overall population of healthcare consumers within a program into multiple risk categories, and provide varying levels of monitoring and care to individual program participants depending on their risk categorization. This is variously termed “risk stratification” or “predictive modeling.” Preemptive interventions triggered by a high-risk stratification will, on average, increase the quality of care, reduce adverse clinical events, and accordingly reduce paid claims dollars. To distinguish high-risk persons from low-risk persons, traditional identification and predictive modeling programs have typically utilized a retrospective claims analysis method that partitions the population based on prior medical utilization or historical health plan claims data, and then sets care levels appropriately.
Predictive modeling based solely on retrospective claims data is of limited accuracy in estimating future risk, however, and therefore needs exist for continued improvement in the field of disease management identification and risk stratification. It is to the provision of improved systems and methods of disease management that the present invention is primarily directed.